Diagnostic imaging, Nuclear Medicine

& Oncology
QUESTIONS MISSED:, Q79 Q83

Q66 – CHECK!

Diagnostic Imaging


Diagnostic Imaging 1
General Radiology 1
Imaging of the respiratory system 6
Imaging of the cardiac system 24
Imaging of the digestive system 31
Imaging of the urogenital system 37
Musculoskeletal imaging 44
Imaging of the CNS & other 55

Radionuclide diagnostics 61

Oncology 74

General Radiology
1. Nature and properties of the radiologic image

Medical imaging is the process of creating visual representations of the interior of the body
for analysis and medical intervention.. Methodologies include:
 X-ray radiography
 Magnetic resonance imaging (MRI)
 Ultrasonography
 Endoscopy
 Elastography
 Thermography
 Medical photography

X-rays (=Radiography)
 X-ray uses: Dense bone absorbs much of the radiation while soft tissue, such as
muscle, fat and organs, allow more of the x-rays to pass through them. As a
result, bones appear white on the x-ray, soft tissue shows up in shades of gray and
air appears black.
 Used on both simple radiography and CT (computed tomography)
 In essence, x-rays produced from x-ray tube, pass through body and based on the
resistance, produce an impression on the film that sits behind the patient.
 Contrast media can be added, such as salts of heavy metals (e.g. barium) organic
iodine, and gas
 X-ray wavelength = 0.01-10nm
 X-ray properties:
- X-ray photons carry enough energy to ionize atoms and disrupt molecular
bonds. This makes it a type of ionizing radiation and thus high dose is harmful
to living tissue.
- Ionizing capability can be utilized in cancer treatment to kill malignant cells
(radiation therapy)
- Diagnostic capability: i.e. X-rays may also be used to detect pathology such
as gallstones (which are rarely radiopaque) or kidney stones which are
often (but not always) visible

MRI
 See question 5

2. Digital imaging. PACS

Nowadays instead of having a photographic film behind people as the x-ray goes through we
have a digital detector. These digital devices include image plates or flat panel detectors.

The system consists of:

 A digital image receptor
 Is in the form of a matrix of many individual pixels. When the pixel area is
exposed to x-ray, an electrical signal is formed that is converted into an
analog data that is then converted into a digital number and stored as one
pixel on the image.
 An digital image processing unit
 Allows for increased processing of the images, including changing contrast
and enhancement, both are very useful.
 An image management system
 Controls movement of images between other parts of the system.
 May be performed by computer component of a digital radiography device or
by a digital image management system (DIMS) that serves many imaging
devices. This is sometimes known as the older and less appropriate name
PACS (Picture Archiving and Communications system)
 Image and data storage devices
 Digital storage also has many obvious benefits such as backing up, speed of
accessibility and saving on space.
 Interface to a patient information system
 A communications network
 A display device with viewer operated controls
 Recorded and displayed as ‘soft copies’

PACS
 Picture archiving and communications system is touched on above as an imaging
system that controls the movement of the x-ray image through the network.
 Electronic images and reports are transmitted digitally via PACS, generally using
DICOM file type (Digital Imaging and Communication in Medicine)

3. Computed tomography - Principles. Current development

https://www.youtube.com/watch?v=VnpqylFYtqI

In essence, this is a machine that takes lots of x-rays from different angles to produce
cross-sectional (tomographic) images of the patient. It also requires a computer.

CT scans can be used with and/or without contract i.e. Oral contrast can be administered if
investigation is required for digestive system (i.e. Chron’s disease, bowel obstruction,
appendicitis etc).

Digital geometry processing is used to generate 3D volume of the inside of the object, with
images taken around a single axis of rotation.

Traditionally images are done in a axial or transverse plane, although other axis are now
possible thanks to advancements in the field.

CT scanning is typically used in acute cases of head pathology (infarction, haemorrhage,

trauma), in the lungs to detect changes in lung parenchyma, in angiography with contrast
and heart CT can be useful to detect changes in the heart or narrowing of the coronary
arteries. Abdominal CTs are also common for a wide range of pathologies. Helps identifies
tumours also.
CT does expose the body to a high amount of radiation, however it is quick. The main
contrast for CT is iodine. Contrast CT will often see a series of images with a native CT,

arterial and venous phase.

The major advancement of CT scanning is 3D CT tomography.

Advantages of CT scans:
- Inherent high-contrast resolution of CT, thus differences between tissues that differ in
physical density by less than 1% can be distinguished.
- Moderate-high radiation diagnostic technique thus improved resolution means we
can avoid invase techniques:
 I.e. CT angiography avoids invasive inseration of catheter
 I.e. CT colography

Ct Scan of Abdomen (Coronal view)

Abdominal area (Saggital view)

4. Ultrasound - Principles. Main applications

https://www.youtube.com/watch?v=STjO4x21-h4 (names for different sound waves)

Ultrasound uses high frequency sound (2-15 MHz) , originating from crystals in a transducer
(piezoelectric effect), which are then echoed back to the transducer as reflected echoes.
- Piezoelectric Effect is the ability of certain materials to generate an electric charge
in response to applied mechanical stress. Due to crystal deformation, it is
converted into electrical energy.
- Ultrasonic transducers or ultrasonic sensors are a type of acoustic sensor divided
into three broad categories: transmitters, receivers and transceivers. Transmitters
convert electrical signals into ultrasound, receivers convert ultrasound into electrical
signals, and transceivers can both transmit and receive ultrasound.

There are a range of frequencies (bandwidths) for different types of imaging. E.g. 2.5-3.5
for abdominal imaging, 5-7 for superficial imaging.

US waves rely on different densities of tissues, where density is increased, proportion of

reflected sound is increased. Where there is a large difference in density, we see echo
shadowing (e.g. in gallstones).

Ultrasound is non-ionising, portable and easier to interpret than many other forms of
imaging making it widely used in almost every specialty.

Main applications:
 Detection of stones (gallstones or kidney stones)
 Visualisation of tendons
 Doppler sonography to visualise vascular flow (e.g. observe abdominal aneurysm)
 Detection of pathoanatomical changes to parenchymal organs
 Echocardiography
 Observation of fetus
 Breast ultrasound to observe mammary masses
 Ultrasound-guided biopsies

5. Magnetic resonance imaging (MRI). Principles. Notion of sequences

MRI scanners use a strong magnetic field and radio waves to generate images of the
organs in the body. It is unionizing however it does take a long time for the scan to occur.
The main principle is that hydrogen atoms are exposed to a strong magnetic signal from
which they emit a detectable radio-frequency signal received by antennas in close
proximity. Hydrogen is abundant in water and fat, so for this reason MRI basically maps the
location of water in the body.

Pulses of radio waves emitted from the MRI machine excite the nuclear spin energy
transition, by varying the parameters of the pulse sequence, different contrast can be
generated based on the relaxation properties of the hydrogen atoms. The two main
sequences are T1 and T2 (more on this below).

After hydrogen atoms are excited by the magnetic signal, they relax to their equilibrium
state. T1 observes relaxation on in the same direction of the magnetic signal
(longitudinal relaxation time) while T2 observes relaxation in a different direction to the
magnetic signal (transverse relaxation time).

The important thing to take away is:

 T1 - Fat is bright, water is dark, gray matter darker than white
 T2 - water is bright, white matter is darker than grey matter
NOTE: IONIZING RADIATION IS NOT USED, RADIOMAGNETIC FREQUENCY IS.

6. Contrast Media - classification. Advantages and limitations

Contrast materials (contrast media) are used to enhance imaging. The main classification is
by delivery:
 Oral
 Rectal
 intravenous/intra arterial

Types include:
 Iodine based
 Used in X-ray and CT, usually intravenous
 Barium-sulfate
 Used in X-ray and CT, commonly oral or rectal
 Note, do not use if there is a risk of gastric perforation
 Gadolinium
 Used in MRI, alters magnetic property of nearby water molecules, enhancing
image
 Saline and gas

Oral contrast materials:

 Commonly barium, used in GI analysis
Rectal contrast materials
 Again, commonly barium used specifically in colonography and rectography
 Where we see air and barium together, this is known as a ‘double contrast’
IV contrast materials
 Commonly iodine (CT and X-ray) or Gadolinium (MRI)
 Used for analysis of internal organs, GI, arteries, brain, breast and soft tissue

Adverse effects include:

 Hypersensitivity
 Thyrotoxicosis
 Nephropathy
 Thyroid dysfunction

7. Invasive and interventional radiology

Interventional radiology is minimally invasive, image guided diagnosis and treatment

Unifying concept behing procedures is application of image guidance to cause as little
disruption to pationet therepy
Interventional radiology is a minimally invasive, image guided diagnosis and treatment
subspecialties of radiology. The unifying concept behind the procedures is the application
of image guidance to cause as little disruption to the patient as possible thereby improving
patient recovery time.

Interventional radiology is a medical specialisation that involves performing a range of

imaging procedures to obtain images of the inside of the body. The interventional
radiologist carefully interprets these images to diagnose injury and disease, and to perform
a range of interventional medical procedures
Procedures include diagnostic:
 Angiography
 Cholangiography
 Biopsy
And therapeutic
 Balloon angioplasty/stent
 Endovascular aneurysm repair
 Embolisation
 Thrombolysis
 Catheter placement
 Chemo and radioembolization
 Pacemaker insertion

Interventional radiology generally uses fluoroscopy (continuous x-ray to observe internal

organs in motion)

Imaging of the respiratory system

8. Imaging methods for the lungs

https://www.google.co.uk/search?
source=hp&ei=gQxKXKiYHaiPmgXYxJbQCQ&q=how+to+interpret+x-
ray+chest&btnK=Google+Search&oq=how+to+interpret+x-ray+chest&gs_l=psy-
ab.3..0i22i30l5.140708.145577..145643...2.0..0.185.3673.4j25......0....1..gws-
wiz.....0..35i39j0i67j0j0i10.88CbbvDE5UA#btnK=Google%20Search&kpvalbx=1

https://www.youtube.com/watch?v=8snjqtrnV1I

https://www.youtube.com/watch?v=L6bnD2wOEmg

TAKE ABCDEF APPROACH (LESSON 2 ON YOUTUBE LINK)

REMEMBER SHOULD SEE 9-10 RIBS, IF NOT THERE’s REDUCED LUNG VOLUME
Imaging of the chest is almost always one of the first diagnostic methods for diseases of the
thorax. We can observe the heart, lungs, pleura, tracheobronchial tree, esophagus,
thoracic lymph nodes, thoracic skeleton, chest wall and upper abdomen. The main
method of analysis is conventional radiography (x-ray).

Conventional radiography
Posteroanterior and lateral chest radiography:
- Simplest of methods, general now digital, reviewed on motors. Two images taken at
90 degrees to each other, with patients breath held at maximum inspiration.

Conventional radiography
 Posteroanterior and lateral chest radiography
 Simplest of methods
 In anteroposterior (AP) views, the positions of the x-ray source and detector
are reversed: the x-ray beam enters through the anterior aspect and exits
through the posterior aspect of the chest. 
 General now digital, reviewed on monitors
 Two images taken, at 90 degrees to each other, with patients breath held at
end of maximum inspiration
 For posteroanterior, patients back should be towards source, facing towards
detector so enters posteriorly and exits anteriorly.
 For lateral, patient should have arms raised above head
 Other radiographic projections
 Only used if patient cannot stand or sit upright. May have to do
Anteroposterior radiographs
Computed Tomography of the Chest
 CT examinations of the chest may be used to observe the arteries and veins within
the mediastinum and hila to facilitate recognition of abnormal masses or lymph
nodes. This is especially useful for early detection of cancer.
 Uses iodine-containing fluid as contrast
Positron Emission Tomography/CT of chest
 Uses emissions of positrons from F-18-fluorodeoxyglucose (FDG), used as a
metabolic tracer to identify increased metabolic rate to distinguish neoplasm and
inflammation from normal tissue.
 If the biologically active tracer molecule chosen for PET is fludeoxyglucose (FDG),
an analogue of glucose, the concentrations of tracer imaged will indicate tissue
metabolic activity as it corresponds to the regional glucose uptake. Use of this
tracer to explore the possibility of cancer metastasis (i.e., spreading to other sites) is
the most common type of PET scan in standard medical care (representing 90% of
current scans). 

Ultrasonography of the chest

 Typically used to evaluate fluid collections within pleural space. May be used to guide
thoracentesis
As a general rule, chest x-ray is always indicated in those with thoracic symptoms. Additional
imaging rules as follows:

Indication for CT
Useful for evaluation of lung parenchyma as thin sections in great detail.
 Clarification of X-ray
 Staging of lung or esophageal cancers
 Detection of metastatic disease from extrathoracic location
 Evaluation of pulmonary nodule
 Suspected mediastinal or hilar mass
 Suspected pleural tumor or empyema (pus collection in plural)
 Determination of source of hemoptysis
 CT guided invasion
 PET/CT to identify increased metabolic activity of tumor
Indication for MRI
Most commonly used for cardiac imaging.
 Evaluation of mediastinal mass
 Superior vena cava syndrome
 Starting of cancer when CT suggests invasion of vessels, wall, heart or diaphragm
 Suspected aortic dissection
 Evaluation of mediastinal or hilar in patients who do not tolerate iodine
 Congenital heart disease

9. Imaging of airways diseases

In viewing the lungs we’re looking for one of four things:

1. Consolidation: pathologic process that fills the alveoli with fluid, pus, blood, cells or
other substances which cause diffuse, multifocal, ill-defined opacities
2. Interstitial: involvement of supporting tissue of the lung parenchyma
3. Nodue/Mass: any space occupying lesion
4. Atelectasis: collapse of part of lung due to decrease in amount of alveoli air and
volume loss and increased density

Atelectasis Differential diagnosis – Airway deviations

This is lung-collapse as a result of loss of air in lung or part of the lung with volume loss due
to airway obstruction or compression of the lung by pleural fluid or pneumothorax. This can
happen physiologically, when we breathe out, but in the cases we see it is obstructive or
nonobstructive, causing a lack of air in the alveoli
- In Atelectasis, trachea is pulled towards side of lung collapse.
- In Pleural effusion, Pneumothorax and large mass (i.e. Mediastinal mass),
trachea is pushed towards to the opposite side.
 Resorption
 Mucus plugging, Tumor, Foreign body
 Relaxation
 Pleural effusion, pneumothorax, rounded atelectasis
Key findings are sharply defined opacity obscuring vessels without air-bronchogram. Volume
loss results in displacement of features. . A common finding in atelectasis is ‘tending’ of the
diaphragm, where the diaphragm peaks upward (blue arrow).

Inflammatory lung disease

Consolidation: Differential diagnosis

 Lobar
 Strep pneumonia, Klebsiella, TB, Aspiration (Bacterial – PUS can
accumulate in alveoli)
 Neoplasia (lung carcinoma with obstructive pneumonia, lymphoma, Bronchial
Airway carcinoma)
 Hemorrhage
 Sarcoidosis
inflammatory lung disease
 Diffuse
 Heart failure (pulmonary oedema seen in CXR), volume overload, low
protein, renal failure, transfusion
 NOTE: If CARDIOGENIC Oedema = Enlarged heart, if NON-
CARDIOGENIC = Size of heart doesn’t change.
 Staph aureus pneumonia, gram -ve pneumonia
 BAC and lymphoma neoplasia
 Hemorrhage due to SLE, Wegener, Goodpasture or TRAUMA
 Multi-focal
 Bronchopneumonia caused by any aetiology, neoplasia
 Consolidation can be acute or chronic. Acute is likely pneumonia, pulmonary
edema or hemorrhage while chronic is most likely neoplasia, sarcoidosis, or
organising pneumonia.
https://www.youtube.com/watch?v=QfiI3j5dlPo
Interstitial differential diagnosis
 Can be Reticular, nodular, high and low attenuation (mostly these four are only
detectable on CT)
 On CXR the most common pattern is reticular, the ground glass pattern is often not
detected, neither is the cystic form.
 Common causes of reticular are:
 Edema (Heart failure)
 Look for kerley B lines. These are long horizontal lines near the
lateral pleura
 Interstitial pneumonia (viral)
 Lymphangitic carcinoma
 Certain drugs
 Causes of cystic disease
 Langerhans cell histiocytosis, lymphangioleiomyomatosis, pneumatoceles
 Causes of fine nodular (ground glass)
 Sarcoidosis, metastases, TB

Differential diagnosis of single nodules and masses

 Most common is granuloma
 Others are bronchial carcinoma, metastasis, organising pneumonia and haematoma

Differential diagnosis of Multiple Masses

 Neoplastic
 Metastases (renal, Testis)
 Infection
TB, fungal, septic emboli
 Inflammation
 Sarcoid (inflammatory), RAN nodules, Wenger’s granulomas, organising
pneumonia
 Vascular
 Pulmonary infarcts (due to injury/inflammation) thus causing embolism (look
for kerley B lines)
 NOTE: Metastases (Much larger nodules) Vs Miliary TB (Minute
tiny spots/opacities all over)

10. Imaging of inflammatory lung diseases

See 9.

11. Pulmonary embolism - current status of imaging

https://www.youtube.com/watch?v=9mjsJ-gCNCU
PE is the embolic occlusion of the pulmonary arterial system, generally due to a thrombus.
Clinical signs are dyspnea, chest pain and haemoptysis. Risk factors include pregnancies,
DVT and others.

Imaging
 Fleischner signs - enlarged pulmonary artery (20%)

 Hampton hump - peripheral wedge of airspace opacity implying lung infarction

 Pleural effusion

Key imaging is on CT (generally lateral), which will show filling defects within the
pulmonary vasculature with acute pulmonary emboli. View in axial plane to view thrombus
(use contrast).

Diff Dx
 Pulmonary artery sarcoma
 Pulmonary artery vasculitis
 Misidentification of pulmonary veins for arteries
 Artefact
12. Pleural diseases

Important pleural diseases

 Pleural effusion (excess pleural fluid, can be caused by transudate, exudate, blood
pus etc… all identical on imaging). Excess fluid can impair breathing by limiting the
expansion of the lungs
- X-ray imaging will show airway (trachea) pushed away from affected side.
I.e. effusion on the left will show deviation of airways to the right.
- Costophrenic recess cannot be seen
 Pneumothorax (air in the pleural cavity, may be traumatic, or teratogenic. Can be
open or closed. Causes lung to collapse, leaves just darkness in lung areas, no lung
markings)
- X-ray imaging will show airway (trachea) pulled towards the affected side i.e.
pneumothorax on the left will show deviation of airways to the left.
 Hemothorax (presence of blood in pleural space, looks like pleural effusion)
 Empyema (localised pleural effusion, causes unilateral pleural collection)
 Pleural thickening (may be due to asbestos, may mimic small pleural effusion,
bilateral generally not of pathologic significance, unilateral is)

 Pleural calcification (commonly result of asbestos exposure, TB and haemothorax)

 Tumors of the pleura (20% malignant, can be described as sub plural nodes/lesions)
 Pleural Plaques (can be minimal, moderate or severe, DD from metastatic carcinoma
is difficult
 Pleural Metastases (due to adenocarcinoma - common metastatic site from lung,
lymphoma and ovary)

 Pleuritis
 Inflammation of the pleura
 Classification
- Fibrinous (dry)
- Exudative fluid filled (with effusion in the pleural cavity – serofibrinous,
purulent, putrid, hemorrhagic)
 Etiology
 A secondary, usually complication of either: pneumonia, tuberculosis, cancer,
pulmonary embolism, congestive heart failure. NOTE: generally viral infection
 Hydrothorax
- When transudate accumulates in the pleura
 Haemothorax
- Blood in the pleural cavity (usually due to chest trauma and broken ribs)
 Hilothorax
- Accumulation of lymph in the pleural cavity
 Pneumothorax
- Air filled
 Pleural empyema
- Abscess near the chest wall open as and purulent fluid pours out into the pleural
cavity. I.e. due to TB

 Symptoms
 Sharp chest pain
 Shortness of breath
 Dry or with sputum dependent on underlyingn cause
- Cough with blood if hemorrhagic
 Fever and chills
 Physical examining
 In patients with large effusion, there are palpitation and low blood pressure, often
high neck vein.
 Main findings are the pleural friction rub and dull percussion sounds
 Diagnosis
 Radiography
- Chest X-ray shows: air or fluid in the pleural space (due to pleural effusion). It
also may show the cause (e.g., pneumonia, a fractured rib, or a lung tumor) of
the pleurisy.
- CT scan and MRI

 Spirometry
- Restrictive type respiratory failure
 Thoracentesis
- Performed over the upper edge of the rib, where the level of the fluid is at its
highest point (between scapular and posterior axillar line).
- The fluid is tested for protein level, blood and tumor cells, culture for bacteria.
Helps to find the cause.
 Blood test
- Blood tests can detect bacterial or viral infections, pneumonia, rheumatic fever,
a pulmonary embolism, or lupus.
 Lung biopsy
- If tuberculosis is suspected
 Complications
 Thoracentesis can cause acute damage.

13. Pulmonary Tuberculosis. Classification. Radiological Appearance of primary

and secondary pulmonary TB.
Infectious disease caused by mycobacterium tuberculosis, an acid fast, aerobic bacilli.
Presents with chronic cough, bloody sputum, fever, night sweats and weight loss.

Pulmonary TB is 90% of cases, can also be Extrapulmonary. A form of extrapulmonary TB is

‘disseminated TB’ or ‘miliary TB’, which makes up 10% of extrapulmonary cases. Can be
symptomatic or asymptomatic.

Classification
     0. No TB exposure
1. TB exposure, no evidence of infection
2. TB infection - no clinical, bacteriological or radiological evidence
3. Active TB - M. tuberculosis cultured with evidence of disease
4. TB not active- history of TB, or abnormal but stable x-ray
5. TB suspect - diagnosis pending

REMEMBER:
1) PRIMARY TUBERCULOSIS XRAY – CAN BE ANYWHERE
2) SECONDARY TUBERCULOSIS XRAY – GENERALLY SUPERIOR UPPER LOBE
3) MILIARY TUBERCULOSIS XRAY- DIFFUSE MINUTE DOT WHITE SPOTS

Primary TB
 Located anywhere in the lung and appears as nonspecific patchy areas of
consolidation or lobar consolidation
 Cavitation is uncommon in primary TB (10-20%)
 Most cases forms tuberculomas which then calcify (known as Ghon lesions)
 Likely to cause ipsilateral hilar and contiguous mediastinal lymphadenopathy (v.
common in children)
 Pulmonary effusions common in children
 Calcification of lymph nodes common, this + Ghon lesion = Ranke complex
Ipsilateral hilar – ghon’s complex
Secondary TB
 Reactivation of TB years later
 Common in posterior upper or superior lower lobes
 Patchy consolidation with poorly defined linear and nodular opacities
 More likely to cavitate, commonly in upper lobes
 Hilar nodal enlargement only in ⅓ of cases
 Tuberculomas only 5%

Miliary TB
 Uncommon, but poor prognosis
 Represents haematogenous dissemination of uncontrolled TB infection
 Miliary tuberculosis
 Definition: Miliary tuberculosis is a form of tuberculosis that is characterized by a
wide dissemination into the human body and by the tiny size of the lesions (1–
5 mm).
- Its name comes from a distinctive pattern seen on a chest radiograph of
many tiny spots distributed throughout the lung fields with the appearance
similar to millet seeds—thus the term "miliary" tuberculosis.
 Microscopically, the lesions show the structure of tubercles with
minute areas of caseation necrosis (Fig. 6.30)
- Miliary TB may infect any number of organs, including the lungs, liver,
and spleen.[2] Miliary tuberculosis is present in about 2% of all reported
cases of tuberculosis and accounts for up to 20% of all extra-pulmonary
tuberculosis cases
 Pathophysiology
- Miliary tuberculosis is a form of tuberculosis that is the result
of Mycobacterium tuberculosis travelling to extrapulmonary organs, such as
the liver, spleen and kidneys. One proposed mechanism is that tuberculous
infection in the lungs results in erosion of the epithelial layer of alveolar
cells and the spread of infection into a pulmonary vein. Once the bacteria
reach the left side of the heart and enter the systemic circulation, they may
multiply and infect extrapulmonary organs. Once infected, the cell-
mediated immune response is activated. The infected sites become
surrounded by macrophages, which form granuloma, giving the typical
appearance of miliary tuberculosis
 Clinical features
- Patients with miliary tuberculosis often experience non-specific signs, such
as coughing and enlarged lymph nodes. Miliary tuberculosis can also present
with enlarged liver (40% of cases), enlarged spleen (15%), inflammation of
the pancreas (<5%), and multiple organ dysfunction with adrenal
insufficiency (adrenal glands do not produce enough steroid hormones to
regulate organ function).[2] 

14. Pulmonary carcinoma. Imaging and staging

REFER TO POINT 96 FOR TREATMENT.

6th most common cancer, leading cause of cancer mortality worldwide. Asymptomatic in
many cases, or unspecific symptoms such as cough and dyspnea.

Types of carcinoma
 Non-small cell lung cancer
 Adenocarcinoma
 SCC
 Large-cell carcinoma
 Small cell carcinoma
Others include lymphoma and sarcoma (rare).

Staging of non-small cell lung cancer

 Stage I - only located in lungs
 Stage II - in lungs and nearby lymph nodes
 Stage III - in lungs, lymph nodes in mediastinal
 IIIA - if nodes on the same side
 IIIB - if nodes on opposite side
 Stage IV - Both lungs, pleural fluid, and metastasized
Staging of small cell lung cancer
 Limited - found on one side of the chest, involving one part of the lung and nearby
nodes
 Extensive - cancer has spread to other regions of chest or other parts of the body
New staging system
 TNM

Imaging of carcinomas is relatively simple. You’re looking for an area of opacity, better
defined than infiltrate, often with spiculated borders (a clear, but jagged border is typical of
a carcinogenic tumour).

This is a great image, look at the speculated lines coming out of the tumour.
15. Benign lung tumour. Echinococcus

Benign lung tumour

So, while the most common pulmonary mass is lung cancer, others also exist. These divide
into two groups:
 Hyperdense masses
 Include granulomas (mass of granulation tissue produced in response to
infection, inflammation or FB) and pulmonary hamartoma (benign neoplasms
composed of cartilage, CT and bone)
 These see internal calcification
 Cavitating masses
 Thick walled abnormal gas-filled sacs in lungs. Usually associated with
nodule. A fluid-air line may be present.
 Etiology due to chronic complications of a pulmonary cyst, other infection or
chronic inflammation.
We also have lung nodules. These are quite common, the cause is not well understood, but
often results of infection, TB, lung abscess or Sarcoidosis (an inflammatory disease that
creates granulomas, probably AI).
Image showing a Axial, thoracic CT, soft tissue window with three findings. One finding in
center of right lung, one cavernous finding and another in contact with the anterior pleura.
Diff dx benign mass (in this case granuloma) or carcinoma with metastasis.

Echinococcus
Genus echinococcus includes six parasitic species of tapeworm. Their relevance for us is
they can form hydatid cysts. These cysts are commonly found in the lungs and produce
daughter cysts that fill the cyst interior.

Hard to distinguish between other opacities, but there is likely to be more than one cyst, so
where multiple appear include this in diff dx.
Note at least three cysts on the right hemithorax. US can confirm daughter cysts within.

16. Occupational lung diseases - Silicosis

Put simply, these are disorders where lung conditions have been caused or made worse by
exposure to materials in the workplace.

Included diseases:
 Occupational asthma
 COPD
 Bronchiolitis obliterans
 Inhalation injury
 Interstitial lung diseases (pneumoconiosis, lung fibrosis)
 Specifically Silicosis and Asbestosis are pneumoconiosis disorders
 Lung cancer

We will specifically consider Asbestosis and Silicosis.

Pneumoconiosis is a restrictive lung disease caused by inhalation of dust. A total of 70,000

deaths in 2013 were due to Asbestosis and Silicosis.

Asbestosis
 Due to exposure to asbestos
 Presents with shortness of breath
 Plain radiograph shows irregular opacities with fine reticular pattern. Calcified or
noncalcified pleural plaques may be evident.
 On CT - centrilobular dot-like opacities, intralobular linear opacities and subpleural
lines can all appear.
 Pleural effusions and pleural plaques are common manifestations.
 Asbestosis
 Definition: Asbestosis is a long term inflammation and scarring of the
lungs due to asbestos.
 Symptoms & Clinical picture include:
- Shortness of breath
- Coughing and wheezing
- Chest pain
- Can lead to respiratory failure
 Pathogenesis:
- Asbestos is inhaled in a working environment which causes an
inflammatory reaction. This leads to fibrogenesis, thus collagen
deposition in the lungs. The fibrotic scarring causes alveolar walls to
thicken which reduces elasticity and gas diffusion (CO2 and O2).
Typically, it requires a relatively large exposure over a long period of
time.
 Diagnosis:
- Positive 3 test (P-elimination, P-collection, P-exposure)
- Anamnesis and check work environment exposure
- Specific chest x-ray structure (honeycomb appearance)
- Spirometry
- CT scan
- Lung biopsy
 Differential diagnosis:
- Check medical history – fibrosis disease, pneumonia etc.
 Complications
- Lung cancer
- Pleural fibrosis
- Pulmonary heart disease
- Respiratory failure
Asbestosis CT

X-ray, showing calcified plaque (L lung) with increased reticular markings. Note how the
plaque just looks like its out of the lung interstitium. It just feels a bit plural. Plaque +
increased markings are key indicators for asbestosis diff dx.
NOTE: SUBDIAPHRAGMATIC CALCIFICATION PRESENT & BILATERAL. IF
UNILATERAL, IT IS NOT ASBESTOS RELATED.

MAIN X-RAY PROPERTIES:

- Subdiaphragmatic calcifications (bilateral)
- Increased markings (fibrosis) (diffuse interstitial fibrosis)
- Calcification.
- Pleural effusion and pleural plaques common (thus airway
deviation to opposite of effected side)

Silicosis
 Caused by the inhalation of crystalline silicon dioxide (silica), often in mining,
quarrying and tunneling. Two forms
 Acute - manifests as alveolar silicoproteinosis
 Classic - manifests as chronic interstitial reticulonodular disease
 Plain radiograph shows bilateral consolidation and/or ground glass opacities in
perihilar regions
 CT - bilateral centrilobular nodular ground-glass opacities with multifocal patches and
consolidation.

 Silicosis
 Definition: Silicosis is a form of pneumoconicosis (occupational lung
disease) caused by inhalation of crystalline silica dust, and is marked by
inflammation and scarring in the form of nodular lesions in the upper lobes
of the lung
 Pathophysiology:
- When small silica dust particles are inhaled, they can embed themselves
deeply into alveolar sacs and ducts in the lungs where gas exchange
occurs thus the lungs cannot clear out the dust by mucous or coughing.
- When the crystalline silica dusts are deposited in the lungs, there’s an
inflammation response which stimulates fibrogenesis thus producing
collagen around the silica particle, thus resulting in fibrosis and the
formation of nodular lesions.
 Symptoms:
- Dyspnea
- Cough
- Fatigue
- Chest pain
- Gradual darkening of the skin (blue skin)
 NOTE: Silicosis can be acute or symptoms can appear after years of
exposure to silica dust thus chronic form.
Note on the L lung, there is increased perihilar markings. Indicative of silicosis
CT of different patient. Significant markings, especially upper lungs.
17. Imaging in diaphragmatic lesions

18. Imaging in diaphragmatic lesions

Primary tumors of the diaphragm are rare. The most common benign cystic lesions are
bronchogenic or mesothelial cysts, the most common solid cyst is a lipoma. The most
common malignant lesion is rhabdomyosarcoma.

Radiologically, most lesions present as smooth or lobulated soft tissue masses

protruding into the inferior portion of the lung, possibly resembling a diaphragmatic
hernia or plural lesion. CT and MRI are prefered as diagnosis on X-ray is unlikely.

Diaphragmatic metastases are rare, clinical symptoms or radiographic features are usually
related to metastasis elsewhere.

The way the question is worded implies this isn’t relevant here, but always consider
diaphragmatic hernias, and check for air under the diaphragm which might indicate
peritoneal perforation.
Bronchogenic cyst

Bronchogenic cyst x-ray

18. Imaging of the mediastinum. Mediastinal tumors

OK, reminder, the mediastinum is the central compartment of the thoracic cavity. It contains:
 Heart
 Great vessels
 Esophagus
 Trachea
 Phrenic and cardiac nerves
 Thoracic duct
 Thymus
 Lymph nodes

Imaging and differential diagnosis:

 Widened mediastinum
 Aortic aneurysm
 Aortic dissection
 Aortic rupture
 Hilar lymphadenopathy (most common)
 Esophageal rupture (with pneumomediastinum and pleural effusion)
 Mediastinal mass
 Mediastinitis
 Cardiac tamponade
 Pericardial effusion
 Thoracic vertebrae fractures (trauma)

This px has achalasia (permanent closure of esophageal sphincter), note how the widening
goes all the way up, unlike if it was related to the aorta.
Tumors
 Anterior
 Substernal thyroid goiters, lymphoma, thymoma and teratoma
 Middle
 Lymphadenopathy, metastatic disease
 Posterior
 Neurogenic tumors

Imaging of the cardiac system

19. Imaging of the heart, coronary arteries, great vessels and peripheral vessels.
20. Imaging of normal heart

OK, so note:
 When you look, if the heart’s right contour is pushed out, this is right atrial
dilation.
 If the top left is sticky out, left atrial dilation
 If the left contour is dilated, likely to be left ventricle, but you may also see right
ventricle dilation there as well
OK, basic imaging
 A front chest X-ray can give us heart shadow and size of mediastinum.
 Excellent for spotting heart failure, pericardial effusion, ventricular
hypertrophy, neoplasia etc.
 Additionally, keep an eye out for calcification. This can be calcification of the
pericardium or the valves themselves!
 CT can show us axial sections of great vessels (good for spotting emboli) along with
producing 3D models of coronary arteries
 3D coronary models help us to identify stenosis - give nitryl glyceride
beforehand in order to better visualise the vessels
 Excellent option instead of angiography

Imaging of peripheral vessels

 Done via CT angiography and MR angiography.
 Can use vascular ultrasound (to locate blockers) and enhance with doppler
ultrasound (to detect blood flow)
 Catheter angiography (uses X-ray + contrast)

21. Imaging of the acquired valve disease

Aortic stenosis
 Most common valvulopathy
 Narrowing of lumen below 1cm2 - symptoms syncope, dyspnea, angina pectoris.
 Commonly caused by degenerative calcification
 Plain radiograph - dilation of ascending aorta (due to stenotic valve ‘shooting’
blood out and remodeling the vessel, with valvular calcification and/or cardiomegaly
appearing later
 Ultrasound - evaluate outflow from aortic valve to determine severity of stenosis
 CT and MRI can provide greater detail
 Dilation of aorta, but normal arch = aortic configuration of the heart -
commonly aortic stenosis
Aortic regurgitation
 Widening and dysfunction of aortic valve eventually leads to symptoms of left-sided
heart failure with dyspnoea and angina (as reduced ejection fraction).
 Caused by root or intrinsic disorders (root = hypertension, CT disorders, aortic
dissection, valvular = rheumatic heart disease, infective endocarditis)
 Plain radiograph - apex may be displaced to left with signs of congestive heart
failure. Aneurysmal dilation may also be present.
 Ultrasound - echocardiology can help assess regurgitant volume and left ventricle
 MRI provides more details

Mitral stenosis
 Narrowing of mitral valve (that sits between left atria and ventricle)
 Presents with progressive dyspnoea with sudden changes of heart rate and CO
 Usually due to rheumatic heart disease
 Notably this causes left atrial enlargement , often with elevation of the left main
bronchus. Can see upper zone venous enlargement due to pulmonary
hypertension along with pulmonary edema (due to congestive buildup)
 Can also see on US, CT and MRI
Mitral regurgitation
 Leaking of the mitral valve - leads to reduced EF as Left Atria pushes blood out of
Mitral as well as aortic valve
 Can be acute (decompensated congestive HF symptoms) or chronic (small changes
relating to the reduced CO)
 Will result in left atrial and ventricular enlargement and occasionally pulmonary
oedema (possibly unilateral, located in the right upper lobe).
 US, CT and MRI can all be used also

21. Myocardial diseases

These are:
 Hypertrophic cardiomyopathy
 Patients present with signs of Left sided congestive heart failure
 Left ventricular wall increases in thickness (without obvious aetiology), can be
associated with right ventricular wall increase
 Radiographic features show enlarged left contour of the heart, MRI and CT
are more useful as they can give more accurate values.
 Dilated cardiomyopathy
 Dilated left ventricle with reduced systolic function due to intrinsic myocardial
damage (e.g. previous MI/ischaemia)
 Radiograph shows enlarged left ventricle with pulmonary edema (softe
pleural effusion as well). Blood cannot be pumped effectively (enlarged
ventricle, decreased muscle thickness.
 US + CT also useful. Df dx = large pericardial effusion
decreased wall thickness
 Restrictive cardiomyopathy
 Least common subtype of cardiomyopathy. Shows marked decrease in
ventricular compliance. Presents with Left and/or right ventricular failure
 There is restrictive filling of the ventricles. In this disease the
contractile function (squeeze) of the heart and wall thicknesses are
usually normal, but the relaxation or filling phase of the heart is
very abnormal.
 Cardiac amyloidosis and sarcoidosis most common causes
 Echocardiography shows diastolic dysfunction, plain radiograph may not
show pathology.
Shows marked decrease in ventricular compliance.
 Infiltrative cardiomyopathy
 Effectively amyloidosis of myocardium. Echocardiography can show left
ventricular wall thickening.

Other diseases such as MI, CAD, myocarditis are all invisible on x-ray imaging. The
exception being MRI, which is now allowing us to determine myocardial viability post
ischaemia.

22. Pericardial affections

Pericardial calcification
 Often a result of previous pericarditis, rheumatic heart disease or malignancies
 Causes restriction of the heart, reducing cardiac output (Left heart failure like
symptoms)
 Appears on chest radiography as hyperintense band along the shadow of the
heart.
 Diff dx: Constrictive pericarditis, chronic adhesive pericarditis, rheumatic pericarditis,
myocardial calcification
 On chest radiography, the location of the calcifications can help differentiate
pericardial calcifications from myocardial calcifications caused by ventricular
aneurysms. While pericardial calcification is seen more commonly over the right
ventricle, myocardial calcifications are seen more commonly over the left
ventricle.
 Pericardial disease
 The pericardium is a thin fibroelastic sac with two layers, the Fibrous and Serous
pericardium (with the serous pericardium in turn divided into the parietal and
visceral pericardium). The fibrous layer sits most superficial to the heart, and is
made up of dense and loose connective tissue, acting to anchor the heart to the
surrounding walls. The serous pericardium, with its two layers, are involved in
lubricating the heart, it is between these two layers (the parietal and visceral layers)
that the pericardial fluid sits (normally about 50ml).
 Pericarditis
 This is inflammation of the pericardium. It can be acute (a few weeks) or chronic
(6+ weeks).
 Etiology
- Viral infection, TB, Myocardial Infarction, Trauma
 Clinical signs
- Sharp chest pain retrosternally (better sitting up, worse lying down. Radiates
to trapezius ridge. No change with exertion)
- Fever, weakness, palpitations, shortness of breath
- A pericardial friction rub in auscultation
 Complications
- Pericardial effusion and cardiac tamponade (see below)
- Chronic pericarditis sees increased fibrosis in the pericardial space, this
similarly to tamponade, limits cardiac output.

 Pericardial effusion
 This is the abnormal accumulation of fluid inside the pericardial cavity (between
parietal and visceral membrane of the serous pericardium). Fluid accumulation in
the pericardial cavity increases pressure around the heart, increasing work of the
heart. Where there is enough pressure to affect the heart it is known as cardiac
tamponade (see below).
 Laboratory testing/imaging
- Echocardiography allows us to observe pericardial effusions, as do CT scans
- QRS voltage is decreased in ECG
Pericardial effusion
 Excess fluid accumulation in pericardial space, can be inflammatory, infectious or
idiopathic
 Plain radiograph shows globular enlargement of cardiac shadow giving water
bottle configuration
 Echocardiography (US) is method of choice to confirm diagnosis and estimate fluid
level
 Can also use CT

Pericardial tumors
 Primary tumors are rare
 The most common benign lesions are pericardial cysts and lipomas. Mesothelioma is
the most common primary malignant pericardial neoplasm
 CT cross sectional imaging is the best way to identify, plain radiograph is generally
ineffective, as is US.

Pericardial cyst ^ Same attenuation as water

23. Aortic diseases. Peripheral vessels diseases

Aortic dissection
 Most common form of the acute aortic syndromes.
 3:1 male to female predominance
 Over the age of 40
 Occurs when blood enters the medial layer of the aortic wall through a tear or ulcer in
the intima. From here, it tracks along the media, forming a section blood-filled
channel within the wall.
 Etiology: common in elderly hypertensives, may also be due to structural
abnormalities.
 Symptoms depend on the nature of the case, but can include ischaemia of an organ
or limb.
 Types A and B
 A: Affects Ascending Aorta and Arch (60% of cases) – Hypertension
predisposition
 B: Begins Beyond Brachiocephalic vessels – Genetic predisposition
 Chest/abdominal radiograph with contrast allows us to detect ‘doubling’ of aorta.
Should be able to observe a true and false lumen that exist separately
 CT may allow for clearer imaging.
Aortic stenosis
 May be atherosclerosis. Look for plaques on the side of the aorta. These can be
stented.
Aortic aneurysm
 Can be thoracic or abdominal, abdominal much more common
 CT and MRI best to observe. Commonly a result of atherosclerosis (Although some
deviation is expected in the male thoracic aorta with age).
 Look for increase of thoracic vessel diameter >4cm, >3cm in abdominal
aneurysm..
 Thoracic aneurysms can mimic Mediastinal masses so be aware.
Thoracic aneurysm. Note how it affects the left contour!

Arterial phase CT showing thoracic aneurysm

Imaging of the digestive system
24. Imaging anatomy of esophagus and stomach

https://www.youtube.com/watch?v=Eg3GeUmOeYE - BASIC CT SCAN OF

ABDOMINAL AREA

Ct Scan of Abdomen (Coronal view)

Abdominal area (Saggital view)

Upper gastrointestinal tract radiography or upper GI uses a form of real-time x-ray called
fluoroscopy and a barium-based contrast material to produce images of the esophagus,
stomach and small intestine. It is safe, noninvasive, and may be used to help accurately
diagnose pain, acid reflux, blood in the stool and other symptoms.
You will be instructed on how to prepare. Your stomach must be empty, so you will likely be
told not to eat or drink anything (including oral medications) or chew gum after midnight the
night before. Tell your doctor if there’s a possibility you are pregnant and discuss any recent
illnesses, medical conditions, medications you’re taking and allergies, especially to contrast
materials. Leave jewelry at home and wear loose, comfortable clothing. You may be asked
to wear a gown.

Esophagus
 We are looking for tumours (commonly SCC), achalasia (a paralysis which causes
dilation), stricture, esophageal varices, diverticular, rupture and fistulas. Also keeping
an eye out for diaphragmatic herniations.
 Non Malignant esophageal disease can be categorised by appearance of
border
 Scleroderma and achalasia both cause lumen dilation
 Esophageal wall thickening can be inflammatory, neoplastic, traumatic or
vascular
 Where we see air and barium contrast, we describe the x-ray as double
contrast. Only using double contrast are we able to view the mucosal lining, useful
for ulcerations etc. Double-contrast image. A smaller quantity of thicker barium liquid
is introduced to the large intestine, followed by air. Double-contrast images show
smaller surface abnormalities of the large intestine, as the air prevents the barium
from filling the intestine. Instead, the barium forms a film on the inner surface.

CT-Esophagus

Achlasia – Esophagus
Esophageal varices –filling
defects

Hiatal herniation

Stomach
 It helps to remember the stomach has a cardia, fundus, body and antrum. We can
observe mucosal folds on plain radiograph but not on CT or MRI.
 We generally don’t do much with the stomach other than looking to observe filling
defects (put it this way, on a list of organs visualised in the abdomen by ‘inside
radiology’ the stomach doesn’t even appear!)
 Do look for ulcers on the lesser curvature though, as well as tumours, cascade
stomach and anatomical variations.

25. Esophageal lesions - diverticula, stricture, tumors, varices

Diverticula
 These are outpouching of the esophagus (herniation of mucosa through the muscular
wall)
 Look for outpouching on double contrast X-ray. Caused by increased intraluminal
pressure or weakened esophageal wall.
o true diverticula: include all esophageal layers
o false diverticula: contain only mucosa and submucosa herniating through
the muscular layer (e.g. Zenker diverticulum)
 Most common is Zenker diverticulum between hypopharynx and esophagus

Stricture
 Narrowing of esophagus, commonly caused by fibrosis induced by inflammatory
and neoplastic process.
 Distal structures are typically caused by gastroesophageal reflux disease
 Benign strictures are typically smooth while malignant strictures are abrupt and
irregular.
Tumors
 Most common tumour is SCC (although relatively uncommon still), adenocarcinoma
rarer (these are mostly related to barrett's oesophagus)
 PET/CT best for staging of disease, CT useful for early detection.
 Chest radiograph can show indirect signs such as widened azygo-oesophageal
recess, thickening of tracheal stripe, retrocardiac or posterior mediastinal mass and
esophageal air-fluid level.

Note the thickening around the esophagus in the centre

Varices
 Dilated veins in the subepithelium, often a result of portal hypertension.
 On X-ray look for change in mucosal form.
Esophageal varices
NOTE: CT scan shows cirrhosis and portal hypertension which leads to varices

26. Imaging of the ulcer

Ulcers can appear anyway through the GI tract, commonly in the stomach and small
intestine (Gastric and duodenal ulcers). Main risk factors are for duodenal ulcers are
H.pylori, NSAIDs and physical stress. Main risk factors for gastric ulcers are over production
of hydrochloric acid.

Imaging is best detected with contrast barium upper GI. Classic Appearance is that of a
>2mm oval mucosal defect with mucosal folds radiating towards the crater. Ulcers are
often associated with a ring of edema which can give a radiolucent ‘waist’ to the ulcer crater
(known as the Hampton line).

It’s important to note you should only give barium where you are confident there is no
perforation. If there is risk of perforation, use oral iodine.

Perforation of the ulcers will often show free air under the diaphragm.

27. Carcinoma of the stomach. Staging. Postoperative imaging

Gastric cancer is a cancer that arises from the mucosal lining of the stomach. It is the most
common gastric malignancy.
 50% have not symptoms, symptoms are non-specific (dyspepsia, anorexia)
 Diagnosis:
o Gastric endoscopy – gold standard
 Adenocarcinoma most common, H.pylori association.
 CT and PET/CT are used, Plain radiograph and US are of limited value
 CT - look for polypoid mass in stomach with wall thickening and ulceration.
Look at the size of that stomach mass.
TNM Classification:
 TX - tumour cannot be accessed
 T0 - no evidence of primary tumour
 T1 - tumor invades lamina propria, muscularis mucosa or submucosa
 T2 - Tumor invades muscularis propria
 T3 - Penetrates subserosa CT
 T4 - Tumor invades serosa
 NX - regional nodes not asses
 N0 - no regional node metastasis
 N1 - 1-2 regional nodes
 N2 - 3-6 regional nodes
 N3 - 7+ regional nodes
 M0 - No metastasis
 M1 - Metastasis

28. Imaging of the bowels. Colon carcinoma

https://www.youtube.com/watch?v=nMLRpJDXR-4
 (see radiology GI part I)
Uses barium contrast. For colon we use barium enema (ensure bowl clear of fecal matter).
Small bowl the barium is either ingested or directly injected.
Tumours of the small bowel are uncommon, mostly present with small bowel obstruction.

Small intestine should be 5cm maximum in diameter. If greater, theres obstruction.

Narrowing of lumen in chron’s disease, apple core sign

Tumours of the small bowel are uncommon, and mostly present with small bowel
obstruction. Small intestines should be 5cm diameter maximum, if they are larger, expect
obstruction. Also look out for coeliac disease, bowel appears slightly dilated with a
less ‘feathery’ appearance. In Crohn's disease look out for narrowing of the lumen (apple
core sign).

Full list of small bowel pathologies

 Obstruction
 Ischaemia
 Adenocarcinoma
 Lymphoma
 Inflammatory Bowel disease
Large Intestines

Large bowel, double contrast very important. Carcinoma of large bowel is usually annular
and appears on barium enema as localised stenosing lesion with napkin ring deformity.
Polyps are routinely identified as well, as are diverticula.  Chronic colitis can give an
irregular shaggy outline to the colonic lumen while ulcerative colitis usually affects
large parts of the colon with the mucosa becoming granular and thickened.

Colorectal cancer often presents as blood in the stool, with changes in weight and tiredness.
Common in old age, with inflammatory bowel diseases being predisposing factors. Often
confirmed with Colonoscopy (although 3D CT is becoming more common). Uses TNM
staging.

NOTE: Often misdiagnosis as we may see feces that mimic tumours! Hence why
patient has to have empty stomach and not eat for a certain amount of time.
Remember: B12 deficiency
here due to loss of terminal ileum. Also, look at comb and halo sign.
29. Imaging of the liver. Focal liver lesions

See GI Part II
See GI Part II
Liver is best observed with CT scan (ultrasounds are used also). We can use different
contrasts to observe the liver:
 Native
 Arterial enhancement (better to detect vascular tumours)
 Portal vein enhancement (60-70 seconds later - better to visualise vasculated
structures)
 Equilibrium (arterial and venous enhancement)

The main conditions we are looking for are:

 Steatosis hepatitis (alcoholic or non-alcoholic)
o Reduced attenuation coefficient compared to spleen (thus darker)
o Focal steatosis (same thing just at a specific part of the liver)
- Results in accumulation of free fatty acids and their breakdown products in the liver
cells (hepatocytes) in a process called steatosis. This initially reversible process
overwhelms the hepatocyte’s ability to maintain llipid homeostasis leading to a toxic
effect as fat molecules accumulate in which over time, due to oxidative stress, an
immune response is triggered.
 Liver cirrhosis
- Cirrhosis is an irreversible distortion of normal liver architecture characterized by
hepatic injury, fibrosis, and nodular regeneration. The clinical presentations are a
consequence of both progressive hepatocellular dysfunction and portal hypertension
(resulting in ascites).

 Cysts
o Hypoattenuation (water) with no enlargement.
 Hemangioma
o Arterial phase (hypervascular tumours enhanced): discontinuous noduler
peripheral enhancements
o Venous phase (hypovascular tumours enhanced): Progressive peripheral
enhancement with centripetal fill-in
o Delayed phase: further fill in therefore hyperattenuating to liver parenchyma

 Focal nodular hyperplasia

 Adenoma
 Liver abscess

Liver abscess – IRREGULAR BORDERS IN COMPARISON TO CYSTS

30. Imaging of the biliary tract. Biliary calculosis

 Ultrasound is used to visualise gallstones

 X-ray can visualise gallstones and calcification of the gallbladder (porcelain
gallbladder)
 We also perform x-ray cholangiography to observe obstruction of the bile ducts.
 Via Endoscopic retrograde cholangiopancreatography or Percutaneous
transhepatic cholangiography

 Cholelithiasis (gall stones)

 Gallstones are solid particles that from bile cholesterol and bilirubin in the
gallbladder. Gall stones are most often asymptomatic of which patients that do have
symptoms often range from mild nausea or abdominal discomfort after eating fatty
of fried foods to severe right upper quadrant or midepigastric abdominal pain, and
lastly, jaundice.
 Etiology:
- Gall stones come in several varieties, but simply put, gallstones are small stones
made up Cholesterol (75-90%) or Bilirubin.
- Depending on the cause and the pathophysiologic mechanism involved,
patience can have one or more of the following:
 Few large individual stones
 Many smaller stones
 Sludge (thickened viscous gel resulting from concentration of bile)
31. Radiology of the “acute” abdomen.

Acute abdominal pain requires

Acute abdominal is a condition of severe abdominal pain that usually requires surgery,
caused by acute disease or injury to internal organs. Examples include:
 Acute appendicitis
 Abdominal aortic aneurysm
 Ruptured gastric ulcer
 Ectopic pregnancy
 Peritonitis
 Ischaemic bowel
 Intestinal obstruction
Simple X-ray & CT
 Appendicitis

 In suspected perforation we can look for free air under the diaphragm in the
peritoneum (pneumoperitoneum)
 In the case of internal obstruction we can see dilation of the bowl, often along with
fluid-air levels (which should only exist in the stomach).
 Volvulus is commonly seen in the sigmoid colon - gives us a ‘coffee bean’ like
structure due to the enlarged sigmoid colon.

 Colonic obstruction is most commonly due to neoplasm or diverticulitis. Barium

enema is the best method for identification of these.
We may give gastrografin which are water-soluble organic iodine preparations where
barium is contraindicated (e.g in perforation).

Best information is taken from AP supine view, although erect view adds more information
about air-fluid levels.

Imaging of the urogenital system

32. Imaging of the urinary system

The urinary system (kidneys, ureters and urinary bladder) are commonly visualised by plain
X-rays, Ultrasound (to differentiate cysts from tumours), Ureoangiography (using X-rays)
MRI and CT.
Plain X-rays allow us to identify enlargement of the kidney by hydronephrosis and
calcification of the renal areas (often calculi in the calyces or renal pelvis, occasionally
calcification of the parenchyma). Additionally, we can witness calcification of the urinary
bladder.

Intravenous urography can be used if the kidney is functioning well enough. It studies the
renal parenchyma, pelvicalyceal system, ureters and bladder (this method has now
largely been replaced by CT urography!). Commonly nonionic water soluble contrast is used.
Immediately after injection into a vein the contrast is visible as a ‘renal blush’ as it is filtered
through the cortex. 3 minutes later, the calyces and renal pelvis are visible, 9-13 minutes
later the contrast is found in the ureters and begins to travel to the bladder. We assess the
kidneys for the following:
 Regular appearance, smooth outlines, size, position, equal filtration and flow
Ureters are assessed for:
 Size, regular and symmetrical appearance, possible obstructions
Bladder is assessed for:
 Regular smooth appearance and complete voiding
Contraindicated in cases where patient has significantly decreased renal function, contrast
allergy or metformin use.

Possible conditions we look for are:

 Chronic pyelonephritis
 Kidney stones
 Renal cell carcinoma
 Transitional cell carcinoma
 Polycystic kidneys
 Anatomical variations (see below)
 Obstructions at pelvic-ureteric junction (PUJ) and vesicoureteric junction (VUJ -
ureter-bladder)
 Filling defects/outpouches of the bladder

33. Radiological anatomy of the urinary system. Variations and anomalies

Kidneys
 Bean shaped bilateral in the posterior abdomen
 Extend from T12-L3 - retroperitoneal (3 vertebrae in length - 4-5 inches)
 Have renal capsule, perirenal fat, renal fascia and pararenal fat
 Internal structure is a cortex and a medulla
 The medulla is made of renal pyramids, which feed the major calyx which
feeds the renal pelvis into the ureter.
 Fed by renal arteries (paired branches of the abdominal aorta)
 Congenital abnormalities
 Pelvic kidney
 In utero, kidneys develop in pelvis and ascend. If this does not
happen, then we have pelvic kidney

 Horseshoe kidney
 Where the two kidneys fuse and get suck below the inferior
mesenteric artery - makes kidneys prone to obstruction. Occurs during
development in the womb

 Renal dysgenesis
 Underdevelopment of the kidney, can be total absence of one or both
or hypoplasia (reduced size)
 Bifid renal pelvis and ureter
 Duplex renal pelvis or duplex ureter due to division of ureteric bud in
embryological development
 Bilateral kidney on same side
 Transplanted kidney

 Anatomic variants
 Persistent fetal lobulation

 Hypertrophied column of Bertin

- Columns of Bertin represent the extension of renal cortical tissue
which separates the pyramids, and as such are normal structures.
They become of radiographic importance when they are unusually
enlarged and may be mistaken for a renal mass (renal
pseudotumour).
Ureters
 25 cm long tubes that travel from kidney to the bladder. Comprised of smooth muscle
and have peristaltic waves.
 Ureteric calculus (or kidney stones) can get stuck in ureters narrowest parts, these
are the ureteropelvic junction, pelvic brim and vesicoureteric junction (where
the ureter enters the bladder)
 CT scans are the gold standard for this

34. Renal calculosis. Hydronephrosis

Renal calculosis
AKA - Kidney stones AKA urolithiasis
 Solid piece of material in urinary tract, typically form in kidney.
 If less than 5mm will pass without symptoms. If larger can block (especially at
ureteropelvic junction, pelvic brim and vesicoureteric junction).
 Caused by high urine calcium, obesity, gout and lack of fluids
 There are four types of kidney stones
 Calcium oxalate (radiodense - show on x-ray)
 Uric acid (radiolucent)
 Struvite (radiopaque)
 Cystine (partially radiodense)
 Non-contrast helical CT scan is the best choice imaging, this detects all stones. If not
possible, an intravenous pyelogram may be performed. Renal ultrasonography may
be useful as it can offer details about hydronephrosis, suggesting stones blocking
outflow, and may show those stones that don’t appear on X-ray.

 Aetiology:
- Risk factors for nephrolithiasis include:
 Calcium oxalate stones
o Hypercalcemia (due to increased GI absorption of calcium)
o Hypercalciuria (impaired tubular reabsorption of calcium)
- Calcium phosphate stones
o Hyperoxaluria (increased calcium oxalate, possibly due to genetic defect)
can cause
- Uric stones
o Over consumption of purines
- Struvite stones
o UTIs
o Obstructive uropathies
 In summary, this shows aetiology is due to genetic factors
alongside dietary factors

Look in the lumbar region of this image, you can see stones present. There are also
phleboliths (small rounded calcifications in the vein) in the pelvis, suggesting this px has high
calcium levels.  
Hydronephrosis
This is selling of the kidney due to obstruction.

It can be acute or chronic. The acute form is almost always due to kidney stones,
accompanied with intense pain. The chronic form may be due to structural abnormalities of
the junctions, compression (due to tumour) or any other possible chronic obstruction.
Is also a condition commonly found in neonates, hydronephrosis can be detected in
neonates by routine screening ultrasound obtained during pregnancy.

Intravenous urogram, renal ultrasonography, CT and MRI can all help with detection of
hydronephrosis. In all cases we are looking for the build up of fluid and thereby associated
distension of the kidney.
35. Renal cell carcinoma. Transitional Cell carcinoma. Staging

Renal cell and Transitional cell carcinoma are the two most common renal cancers.

Renal cell carcinoma originates from the lining of the proximal convoluted tubule and is
responsible for 90-95% of kidney cancers. The disease can advance far before detection,
common symptoms include blood in urine, flank pain, weight loss, fever and high blood
pressure. RCCs commonly spread to lymph, lungs, liver, adrenal glands, brain or bones.
- Patients are generally 50-60 years old

On radiological imaging we are looking for a solid renal lesion which disturbs the renal
contour, often with a lobulated margin. Most lumps on imaging are cystic (main diff dx),
use US to differentiate. 10% of RCCs will contain calcifications. Pelvic and abdominal CT,
US and MRI are the most common diagnostic tests.

Staging:
 Stage 1 - diameter 7cm or smaller, no metastases or lymph involvement
 Stage 2 - larger than 7cm but still localised to kidney
 Stage 3- any size tumour, involvement of lymph, but no metastasis OR tumour
spread to fatty tissue around the kidney but no spread to nodes or other organs
 Stage 4 - Tumour that has spread to fatty tissue and fascia OR involvement of more
than one lymph node in the area OR involvement of any lymph node not near the
kidney OR distant metastases
We can also use TNM staging.
Transition cell carcinoma (aka urothelial carcinoma) is the most common type of bladder
(97% of the time), ureter and urethra cancer. It is the second most common type of kidney
cancer, but only accounts for a small fraction of these. It arises from transitional epithelium.

 TCC in the urethra

 Can be papillary (more common) or non-papillary (less common, higher
grade)
 CT can struggle to ID tumours due to their small size, conventional urography
is often more useful as it detects filling defects - look for goblet sign (ureter is
focally dilated by an intraluminal mass)
 TCC in bladder
 Most common tumour in whole urinary system
 Haematuria is the most common complain, tumour located at vesicoureteric
junction may prevent urination and cause hydronephrosis.
 Can be superficial (majority) or invasive)
 CT shows tumours as masses protruding into the bladder, or as thickening of
the bladder wall. Masses may have calcifications. Traditional urography plays
less of an important role here. MRIs are still useful for distinguishing T1 from
T2. PET DOES NOT WORK! (FDG is excreted into the ruine so it is
unsuitable for diagnosis)
Staging (TNM):
 T1 - invaded through lamina propria into subepithelial CT
 T2 - into muscularis propria
 T2a - only invades inner half of muscle T2b invades outer half
 T3 - invasion into perivesical tissues
 T3a - microscopic, T3b macroscopic
 T4 - Direct invasion into adjacent structures
 T4a - prostate, uterus, vaginal vault. T4b - pelvic and/or abdominal wall
 N0 - no nodes
 N1 - single node
 N2 - multiple nodes (2-5)
 N3 one or more nodes >5cm
 M0 - no metastases
 M1 – metastases

These are then grouped Stage I-IV

36. Imaging in obstetrics and gynecology

Obstetrics
Ultrasound is vital in monitoring normal and abnormal pregnancies.

First trimester
 Transabdominal scanning with a full bladder (as this displaces gas-containing bowel).
 Gestation sac can be ID’d as early as 5-6 weeks after first day of last menstrual
period, transvaginal scanning can ID sac as early as 4 weeks.
 By week 10 the sac occupies most of the uterine cavity and fetal node can be ID’d
from 7th week (along with heartbeat), with a fetal head at 14 weeks.
 Abnormalities in early pregnancy: missed abortion, live abortion, anembryonic
pregnancy, hydatidiform mole, ectopic pregnancy

Mid and late pregnancy (2nd and 3rd trimesters)

 18-20 weeks normal time for routine examination, documents fetal number, fetal
heart beat, fetal position, gestational age, abnormalities (below), placental location,
amniotic fluid amount
 Abnormalities: Neural tube defects (anencephaly, spina bifida etc), thoracic and
heart defects (including defects of the great vessels), congenital diaphragmatic
hernia, structural abdominal defects
 Where we do Chorionic villi sampling for genetic testing, this is US guided
 Placenta is easily identified by US and is localised and recorded.
CT and X-rays should not be used in pregnant women, however there is no evidence that
MRI’s are harmful. This said, MRIs are not recommended in the first trimester.

Gynecology
 US of the female pelvis is the primary investigation for many gynae problems
including congenital abnormalities, pelvic masses, pelvic inflammatory disease,
ovarian function and pathology testing, and assessment of intrauterine
contraceptives.
 A common use of US in gynecology is the evaluation of PCOS and other cysts (these
include cystadenoma, cystadenocarcinoma, dermoid, teratoma).
 CT and MRI are better for assessment of malignant tumours, with MRI the gold
standard. Plain x-ray can be useful, as it can help to differentiate fibroids (which often
calcify and have a characteristic mottled visage)